Jeschke et al.

Stem Cell Research & Therapy (2019) 10:337

https://doi.org/10.1186/s13287-019-1465-9

SHORT REPORT Open Access

Allogeneic mesenchymal stem cells for

treatment of severe burn injury
Marc G. Jeschke1,2,3,4,5* , Sarah Rehou1,2, Matthew R. McCann1 and Shahriar Shahrokhi2,3

Abstract
The most important determinant of survival post-burn injury is wound healing. For decades, allogeneic
mesenchymal stem cells (MSCs) have been suggested as a potential treatment for severe burn injuries. This report
describes a patient with a severe burn injury whose wounds did not heal with over 18 months of conventional
burn care. When treated with allogeneic MSCs, wound healing accelerated with no adverse treatment
complications. Wound sites showed no evidence of keloids or hypertrophic formation during a 6-year follow-up
period. This therapeutic use of allogeneic MSCs for large non-healing burn wounds was deemed safe and effective
and has great treatment potential.
Keywords: Burns, Cell therapy, Mesenchymal stem cells, Wound healing

Introduction able to migrate to the source of tissue damage to support

In addition to substantial morbidity and mortality during
the acute phase of critical illness, burn injury can also
lead to post-injury scar tissue formation with long-term
functional and psychosocial consequences [1]. The use
of stem cells in the treatment of burns remains challen-
ging and continues to be an area under intense research
[2, 3]. In 1984, the New England Journal of Medicine
reported the first use of autologous cultured human epi-
thelium to treat two pediatric patients with > 97% total
body surface area (TBSA) involvement, where autolo-
gous full-thickness biopsies were cultured and single-cell
suspensions were expanded to provide coverage [4]. This
provided evidence that isolated biopsies contain cells
that when cultured can preserve the potential to initiate
regenerative processes upon transplantation to the
wound site. Recent efforts have focused on identifying
ideal cell sources with these mitigating capabilities.
Currently, human umbilical cord and amniotic mem-
brane MSCs (mesenchymal stem cells) are being explored
for potential therapeutic use. These sources are considered
non-invasive, low cost, and abundant. The MSCs from
them can be easily grown and maintained in tissue culture
[5]. Once administered to the donor bed, these cells are
* Correspondence: marc.jeschke@sunnybrook.ca
1
Sunnybrook Research Institute, Toronto, Ontario, Canada
2
Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, 2075 Bayview
Ave. D7 04, Toronto, Ontario M4N 3M5, Canada
Full list of author information is available at the end of the article
endogenous stem cells. Additionally, their immunosuppres-
sive properties allow them to withstand acute cellular rejec-
tion [5]. Trials completed to date have not demonstrated
long-term adverse effects, such as neoplasm formation or
cellular rejection with the use of MSCs [6].
The amniotic membrane is the innermost fetal mem-
brane layer of the amniotic sac which protects the fetus.
It also provides a physiologically and immunologically
distinct environment for the fetus to thrive [7]. In 1912,
Stern and Sabella conducted pioneer work on amniotic
membranes where they successfully used freshly isolated
amniotic tissue to treat a relatively small burn (9 square
inches) [8]. This pivotal work paved way for clinical use
of MSCs. When removing the dressing from patients’
after 2 days, Stern documented the presence of distinct
membrane layers [8]. Perhaps unknowingly, Stern had
identified that MSCs were able to adapt and integrate
with the wound while the chorionic layer contained epi-
thelial cells that could be removed.
While the application of amniotic MSCs in burn care
has fluctuated throughout the last century, there was a
resurgence in their use in the 1990s. Since then, we have
developed a better understanding of the amnion’s immuno-
regulatory, antimicrobial, anti-fibrotic, and anti-scarring
characteristics [9]. These characteristics can improve
wound healing in patients with severe burns [10].
However, treatment of full-thickness burns with the

© The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Jeschke et al. Stem Cell Research & Therapy (2019) 10:337
amniotic membrane continues to be challenging with
the risk of microbial contamination and infection
[11]. To overcome the potential for contamination
and optimize cellular expansion, we opted for experi-
mental therapy with MSCs in a patient with severe
full-thickness burn injuries.
Case report
Local hospital
A male in his mid-twenties was admitted to a local, ter-
tiary care center with > = 70% TBSA burns, mostly full
thickness, and had also sustained smoke inhalation in-
jury as a result of a house fire. The areas involved in-
cluded the chest, back, bilateral arms, hands, thighs, feet,
and buttocks. The patient’s initial surgeries included
escharotomy of his right forearm and a transmetatarsal
amputation of the right and left foot. He had in total 13
surgeries for excision and application of skin grafts, a
tracheostomy, an ileostomy for fecal diversion due to
non-healing buttock wounds, and a percutaneous gas-
trostomy tube placement. During this time, the patient
developed chronic infections with multi-drug resistant
Pseudomonas. His pain management had also become
increasingly complicated. Eighteen months post-injury,
approximately of more than one third of his initial
wounds remained open and were severely infected with
a plethora of bacteria. At this point, the patient was
transferred to a specialized burn center (Fig. 1).
Fig. 1 Open and infected wounds 18 months after burn injury. Posterior trunk, 72 weeks post-injury (a); posterior trunk, 73 weeks post-injury (b);
anterior trunk, 73 weeks post-injury (c); anterior lower extremities, 73 weeks post-injury (d)
Page 2 of 6
Provincial burn center
On admission to our burn center, initial assessment
demonstrated wounds with significant hyper-granulation
with profound bacterial colonization/infection. These
wounds, including the back, chest, right arm, and bilat-
eral legs, were subsequently debrided with application of
allograft. Documented assessments of the sites over the
next 2 weeks found that the allografting failed and that
“the majority of the wounds remained open, and infected
with minimal to no healing or epithelization, particularly
the large regions of the back and buttocks”. The wounds
were infected and contaminated with Enterobacter cloacae,
Enterococcus species, Klebsiella pneumoniae, Pseudomonas
aeruginosa, Staphylococcus aureus, and Yeast. The allograft
application failed to result in vascularization, and subse-
quently, the wounds did not heal. Given the longstanding
history of the wounds and multiple complications and fail-
ures, it was determined that conventional treatment would
not result in a favorable outcome. Therefore, a novel treat-
ment approach was needed in order to adequately heal
these wounds. In due course, we sought approval from our
institution to use amniotic and umbilical allogeneic stem
cell transplantation from two donors. The hypothesis was
that allogeneic MSCs could induce an immune response
that would help to clear the infection. We also believed that
these cells would stimulate the release of growth factors
which would accelerate wound healing. In a later surgery,
the hyper-granulated areas were excised and the cord-
lining membrane mesenchymal stem cells (CL-MSCs) were
Jeschke et al. Stem Cell Research & Therapy (2019) 10:337
applied topically using a fibrin sealant spray along the back
and buttocks. Allografts were then applied over the area to
temporary close and protect the wounds.
Three weeks postoperatively, the attending staff surgeon
determined that the patient’s open wound decreased to
approximately half of the original one third and showed
significantly decreased infection. At this stage, another
surgery was undertaken, at which time, commercially pro-
duced MSCs were subcutaneously injected into the hyper-
granulated tissue. One week after the second MSC applica-
tion, the patient’s open burn wounds decreased to about
one seventh. A final surgery involved injecting the wound
bed with 20 cm3 of platelet-rich plasma and application of a
negative-pressure wound therapy device.
Two months after the second MSCs treatment, less
than 3% of wounds remained open, at which point a
final surgery was performed in order to autograft from
the remaining wound using the patient’s scalp skin as
donor. Five months after admission to our burn center
and four and a half months since the initial MSCs treat-
ment, the patient was discharged for rehabilitation care
with no open wounds.
Long-term assessment
Nineteen months post-discharge from our burn center, the
patient returned for contracture release of his right axilla
and hip. At this time, we found no evidence of hypertrophic
scars, keloids, or wound breakdown. Scar contracture re-
leases with transposition flaps were undertaken on the right
Fig. 2 Six years after mesenchymal stem cell application. Posterior trunk (a), anterior trunk (b), posterior lower extremities (c), right upper
extremity (d)
Page 3 of 6
axilla and hip. During this time, the patient underwent right
elbow ulnar nerve neurolysis, excision of heterotopic ossifi-
cation, and soft tissue contracture release.
At a 6-year follow-up, the patient was in excellent
health with substantial amounts of complete epitheliali-
zation, particularly on the back, buttocks, and bilateral
legs. Importantly, there was minimal hyperpigmentation
and hypertrophic scarring as well as no evidence of ke-
loids following MSC administration (Fig. 2). The patient
maintained excellent ranges of motion and transitioned
well into daily activities of living.
Methods
Ethics
Treatment: This patient was profoundly ill and we con-
tacted our institutional Research Ethics Board and the
Chief Medical Executive to ask for compassionate use
approval. Compassionate use approval was granted, and
subsequently, we obtained consent from the substitute
decision maker for treatment. The patient was assented
at a later time during his hospital stay. Case report: A
case report does not require approval from our institu-
tional Research Ethics Board. Consent was obtained
from the patient to allow their information and images
to be published.
Isolation, expansion, and culture of MSCs
Our initial seeding of CL-MSCs into the burn wounds was
conducted using human umbilical cord lining membrane
Jeschke et al. Stem Cell Research & Therapy (2019) 10:337
(subamniotic) MSCs isolated using a previously estab-
lished protocol in our lab [12]. Briefly, human umbilical
cord samples from healthy donors were screened, dis-
sected at the envelope membranes, and cultured. These
distinct CL-MSCs have membrane expression of CD73
and CD105, MSC markers, and Oct-4, Nanog, and SSEA-
4, preserved stem cell markers Oct-4. However, they lack
Sox-2, FGF-4, TERT, and Rex-1markers found on other
embryonic stem cells. Cultures were tested for microbio-
logical contamination before being prepared for clinical
application.
Initial MSC seeding
After the hyper-granulated tissue was excised and
cleaned, CL-MSCs were placed in Ringer’s lactate and
mixed with fibrin sealant (3 million cells/mL). Four
milliliters of the stem cell/sealant cocktail was topically
applied to the back, buttocks, and legs. The wounds
were allografted for protection, covered using paraffin
gauze and antimicrobial dressings, and finished with bol-
ster dressings.
Secondary MSC injections
We next used Ovation® MSCs derived from the chorion
layer of donor placentas from Osiris Therapeutics, Inc.
(Columbia, MD, USA) [13]. Ovation® MSCs were com-
mercially available at the time. However, Osiris Thera-
peutics, Inc., stopped manufacturing the product in
2014. Twelve vials of MSCs were thawed and individu-
ally placed in Ringer’s lactate solution before being
injected under the granulated tissue in the patient’s back,
buttocks, and legs. Injections were conducted homoge-
nously throughout the open wound regions and were
systematically placed near the perimeter of the wounds
to stimulate re-epithelization. Once more, the wounds
were protected with allograft and subsequent dressings
were applied.
Discussion
In this report, we describe the use of stem cell therapy
on a male patient in his mid-twenties with a 70% TBSA
burn injury. Eighteen months prior to admission to the
burn center, conventional means of burn treatment left
this patient with multiple in-hospital complications and
in an overall poor condition. With the administration of
allogeneic MSCs, we were able to reduce open wounds
from one third to less than 3% and significantly heal in-
fections in a short time period. However, we were con-
cerned about the possibility of long-term keloids and/or
hypertrophic scarring with therapeutic use of MSCs. We
observed the patient for over 6 years and found the pa-
tient had an excellent wound recovery trajectory, with
limited scarring relative to similar burn injuries and no
adverse side effects, such as neoplastic formation or
Page 4 of 6
adverse immune response. The lack of severe hyper-
trophic scarring is particularity remarkable considering
the amount of time the wounds had remained open and
infected. This is even more surprising since most of his
wounds were full-thickness, which are generally slow to
heal and have a greater risk for developing pathological,
hypertrophic scars [14].
While the use of MSCs in burn wounds treatment has
advanced in recent years, most reported trials describe
patients with < 80% TBSA of which, only approximately
30% are full-thickness burns [15]. Most are partial and
deep-partial thickness burns with minimal %TBSA [16].
In contrast, this patient was admitted with a large sur-
face area (70% TBSA) burn, mostly full-thickness, as well
as an inhalation injury with a resultant mortality risk of
80% based on the modified Beaux score [17]. Despite the
observed recovery, the mechanisms by which MSCs con-
tribute to wound healing in patients with large, severe
burns remain unknown.
It has been postulated that MSCs serve dual functions.
They are thought to first release mediators that influence
inflammation and stimulate angiogenesis and then dif-
ferentiate into multilayered epidermal-like structures
that aid in wound closure [18]. In a seminal paper by
Wu et al., it was shown that differentiated bone marrow-
derived MSCs released VEGF-α and Ang-1 which stimu-
lated endothelial cell proliferation and subsequent tissue
migration, ultimately increasing angiogenesis [19]. In ro-
dent burn models, human-umbilical MSCs modulated
expression at the cellular level, specifically increased
VEGF expression upstream of wound site microvessel
formation, increased anti-inflammatory mediators IL-10
and TSG-6, and decreased proinflammatory cytokines
IL-1, IL-6, and TNF-α [20]. It is possible that exosome
release may account for some of the anti-inflammatory
effects observed. Exosomes contain miR-181c which act
to suppress toll-like receptor 4 expression and may lead
to reduced downstream pro-inflammatory factors, TNF-
α and IL-1β [21].
Additionally, the use of either the amniotic membrane
or CL-MSCs might have different results. The use of the
amniotic membrane in pediatric patients with partial-
thickness facial burns did not significantly improve heal-
ing time, length of hospital stay, or development of
hypertrophic scars [22]. In addition, dehydrated and irra-
diated amniotic membranes have shown little promise
[23]. Since the use of MSCs in the clinical settings, spe-
cifically in wound care, has not yet been fully elucidated,
we elected the use of two distinct methods: (1) a fibrin
sealant-based topical application and (2) direct tissue in-
jections. The first method followed by a dressing has
been shown to be both safe and effective in applying
MSCs and allowing them to persist and integrate within
the wound area [24]. Evidence also shows that local
Jeschke et al. Stem Cell Research & Therapy (2019) 10:337
injections of MSCs to and around the wound bed have
been shown to accelerate wound healing in radiation
burn treatments [25]. We hypothesize that the two treat-
ments served separate functions in repairing the dam-
aged tissue; the initial topical application served to quell
inflammation and stimulate angiogenesis while the injec-
tions allowed for appropriate re-epithelization of the
wounds.
One of the most interesting aspects during the treat-
ment period was how the application of MSCs resulted in
a reduction of burn wound infection. After the initial
MSC application macroscopically and microscopically, the
burn wounds cleared allowing allograft to be placed and
initiate wound healing. MSCs have been studied in terms
of their anti-infective properties, and several studies dem-
onstrated that MSCs exert strong anti-infective effects via
various mechanisms. A recent study by Johnson et al.
showed that MSCs interact with type I and type II macro-
phages phenotype most likely by secretion of cathelicidin.
The authors concluded that therapy with activated MSCs
might be an effective non-antimicrobial approach to treat-
ment of chronic, drug-resistant infections [26]. Another
study by Hutton et al. found that MSCs increase bacterial
killing capacity and bacterial clearance. They also showed
that MSCs secrete an antimicrobial peptide LL-37 [27].
The signal of increased bacterial killing and clearing was
confirmed by Johnson et al. as they showed that Cramp,
an antimicrobial peptide, was significantly increased with
MSCs [26]. It therefore appears that MSCs have strong
anti-infective properties which we observed in our case re-
port as well.
This case provides evidence for rapid re-epithelization
of open wounds with MSCs without long-term conse-
quences of hypertrophic scar formation, which inhibit mo-
bility and have negative psychological effects. This case
also demonstrates the immense potential of MSCs in the
acute phase of burn care. Future research should investi-
gate the efficacy of MSC use in the severely burned patient
on a large scale.
Abbreviations
CL-MSC: Cord-lining membrane mesenchymal stem cell; MSC: Mesenchymal
stem cell; TBSA: Total body surface area
Acknowledgements
The authors would like to express their appreciation to Anne Hayward, Social
Worker, for her invaluable effort, time, and comments on the manuscript.
The authors would also like to thank the Ross Tilley Burn Centre staff for
their support.
Authors’ contributions
MGJ, SR, and SS made substantial contributions to the conception and
interpretation of the work. All authors were involved in drafting the work,
revising it critically for content, and approved the final version for
publication.
Page 5 of 6
Funding
Canadian Institutes of Health Research # 123336, Canadian Institutes of
Health Research CMA151725, National Institutes of Health #R01GM087285,
Ontario Institute of Regenerative Medicine.
Availability of data and materials
Not applicable.
Ethics approval and consent to participate
Treatment: Consent was obtained. A case report does not require approval
from our institutional Research Board.
Consent for publication
Consent was obtained from the patient to allow their information and
images to be published.
Competing interests
SS received funding from Acelity and Smith & Nephew. All other authors
declare that they have no competing interests.
Author details
1
Sunnybrook Research Institute, Toronto, Ontario, Canada. 2Ross Tilley Burn
Centre, Sunnybrook Health Sciences Centre, 2075 Bayview Ave. D7 04,
Toronto, Ontario M4N 3M5, Canada. 3Division of Plastic and Reconstructive
Surgery, Department of Surgery, Faculty of Medicine, University of Toronto,
Toronto, Ontario, Canada. 4Department of Immunology, Faculty of Medicine,
University of Toronto, Toronto, Ontario, Canada. 5Institute of Medical Science,
Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.
Received: 19 June 2019 Revised: 11 October 2019
Accepted: 22 October 2019
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